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Payer Insights to the Provider at the Point of Care
Session 32, February 12, 2019
Nancy Beavin, Interoperability Leader, Humana Inc.
Dr John Michael Robertson, MD
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Nancy Beavin
• No real or apparent conflicts of interest to report.
Dr. John Michael Robertson, MD
• No real or apparent conflicts of interest to report.
Conflict of Interest
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• Review Learning Objectives
• Bridging The Gap
• Why Payers Are Interested in The Space
• Challenges Faced by Providers Today
• How Can We Mitigate Those Challenges
• How Can This Process Work
• Use Case – What are we doing today
– Payer to Provider communication
Agenda
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Learning Objectives
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Demonstrate value of Payer Insights delivered into the EMR at
the point of care
Describe the ability to provide near real-time feedback to payers
on clinical decisions
Evaluate the value to the provider, patient, and payer of near
real-time bi-directional communications at the point of care
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Bridging the Gap
360° View
Payer based health record integrated into
physician workflows via web services
Points of Care Alerts
Physician can receive actionable
alerts from within the progress note
Future Quality Capabilities
Explore abilities to design additional payer
agnostic tools such as a Patient
Assessment Form (PAF) template, etc.
Streamline Chart
Request Process
Faster and more secure than traditional
methods
Reduce Practice Disruption
No complex 3
rd
party portals needed and
seamless transfer of clinical data to payer
without intervention
Real-Time Benefit Check & ePA
Provide real-time patient-specific drug
coverage and pricing during eRx workflow,
including formulary alternatives and ability
to initiate ePA from EMR
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Advancing Interoperability
Direct integration into provider workflows
Future Capabilities
Explore abilities to design a payer agnostic
PAF template and more
Reducing Practice Disruption
Automated bi-directional data responses
Improving Health Outcomes
Integrating payer based health data to
physicians at the point of care
Why Payers Work in This Space
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What We’ll Cover Today
Lets understand the
challenges faced
today by providers
and practices
What solutions can
help mitigate these
challenges
How the process
can work
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Understanding the Challenges
Provider Frustrations
• More time spent documenting than
face-to-face patient care
• Inefficient and time consuming
methods to monitor and achieve
care benchmarks that may differ
payer to payer
• Difficult for providers to see what
is happening outside of their
practice
• Care and compliance are often
reactive vs proactive
Practice/Staff Challenges
• Wasted time/loss of resources
• Third-party practice disruptions
• Current methods can be unsecure
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Mitigating Provider Frustrations
• Presenting Payer clinical data to the provider in
his workflow at the point of care
• Making this clinical data ‘actionable’ from the
message into the progress note
• Providing physician notes back to the payer to
respond to care gaps/alerts that may not be closed
with a claim or data submission (i.e., care gap that
is not applicable or already closed)
• Providing a 360° patient view of the member
using the payer’s clinical data from providers
outside their own health system or EMR
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Who uses this data?
• New Patient/Payer Member -
– PCP
– Specialist
– Urgent Care, Telehealth
– Hospital, ER
• Existing Patient/Payer Member -
– PCP
– Specialist
– Urgent Care, Telehealth
– Hospital, ER
Use Case–Retrieve Encounter data
API
•Member schedules face to face visit
with provider triggering the API to
inform Humana
•Humana releases the Member
Summary to the provider through the
API
•Provider is sent the Member Summary
and some items are actionable. Any
responses are sent back to Humana.
•Humana refreshes Payer Based Health
Record daily to provide most up to date
clinical information available to provider
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Use Case–Retrieve Encounter data
How Can it Work
• Provider completes a patient encounter
• Provider authenticates the encounter
• EMR provides technology to electronically provide encounter record to payer
• Checks patient eligibility for the date of service
• Filters sensitive data
• Assures this is not a self-pay encounter
• EMR provides Encounter summary in available format, discreet data if possible.
• Payer has encounter data for Quality measure reporting, Risk Adjustment, Claims Adjudication
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• New Patient/Payer Member -
– PCP
– Specialist (those treating Chronic Conditions)
• Existing Patient/Payer Member -
– PCP
– Specialist (those treating Chronic Conditions)
Use Care - Actionable Payer Data
Payer Clinical Data at the Point of Care
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• Using the Payer Based Health Record
– Mostly Claims Based discreet clinical data, may include,
• Quality data – Suspect Conditions, HEDIS measures, Care Alerts, HCC
history
• Payer Program participation
• Hospitalizations
• Lab Results
• Prescription history
• Procedures
• Immunizations
• Allergies
– Identifying Triggers within EMRs
• Scheduled appointment
• Eligibility Check
• Initiate Request
What are we doing?
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• Clinical Decision Support screens
– HEDIS measures, Care Alerts, Potentially clinically inferred conditions,
Undocumented chronic conditions
– Can be addressed in current encounter
– Can be assigned to another caregiver
– Can be suppressed to address at a later time
• Problems, Allergies, Immunizations, Procedures
– Add items not currently known by the practice where indicated
• Medication History
– Add Medications not currently known by the practice into the Med List
• Hospitalizations
– Note for reference or education of the patient
Parsing data in provider workflow
Making it actionable
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• Allows provider to send a “text” like communication to Payer for
information that would not come to the Payer via a claim or
supplemental data feed.
• Example
– Payer sends open HEDIS measure for a Mammogram
– Patient has had a double mastectomy
– Provider can message this appropriate information to payer
Use Case Real-time communication
from provider to payer
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Mitigating Practice Frustrations
• Automate the process of providing medical charts
to payers for the purposes of closing gaps in care,
risk adjustment, etc.
• Reduce the effort needed for provider staff to
complete this task
• Eliminate the need for the use of third party
solutions that may be manual or expensive
• Eliminate the need for payers to send
representatives into the practice
• Eliminate the need for providers to configure
and maintain their systems to allow payers to
have remote access
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What Humana is Doing
Humana is working with industry initiatives and directly with EMRs to
integrate these solutions directly into providers and staff workflows
Industry
Humana sponsors a number of industry groups that focus on
integrating and accelerate interoperability solutions:
• DaVinci (HL7 industry work group) – focused on accelerating
adoption of HL7 Fast Healthcare Interoperability Resources
(HL7® FHIR®) as the standard to support and integrate value-
based care (VBC) data exchange across communities
• P2FHIR (ONC convened group) – focused on accelerating
adoption of FHIR APIs in the industry
• Argonaut Project (HL7 industry work group) – aims to rapidly
develop a first-generation FHIR-based API and Core Data
Services specification to enable expanded information sharing for
EHR and other health information technology
• CARIN Alliance – focused on working collaboratively with other
stakeholders and government to overcome barriers in advancing
consumer-directed exchange
EMRs
Humana is working with multiple EMRs to
provide solutions Payer Exchange
solutions into the EMR workflow that are:
• Real-time
• Bi-directional
• Providing real-time responses back
to payers beyond claims and medical
records
• Easy to implement and use
• Are All Payer solutions
